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RESEARCH PAPER

Team nursing: experiences of nurse managers in


acute care settings

AUTHORS ABSTRACT

Dr Lorraine Ferguson Objective


AM RN, RM, DipNEd, BSocSc, MPH, PhD This study aimed to explore and describe nurse
Adjunct Associate Professor, School of Nursing and managers experiences with a teambased approach to
Midwifery, College of Health and Science, University of nursing care in hospital settings.
Western Sydney, New South Wales, Australia.
Design
l.ferguson@uws.edu.au
A qualitative descriptive study using interviews to
Dr Jane Cioffi explore managers experiences of team nursing.
RN, BAppSc(Nsg), GradDipEd(Nsg), MAppSc(Nsg), PhD
Setting
Adjunct Associate Professor , School of Nursing and
Medical and surgical wards in an acute care setting
Midwifery, College of Health and Science, University of
Western Sydney, New South Wales, Australia. Participants
j.cioffi@uws.edu.au Five nurse managers (four female and one male)
who volunteered to participate following calls for
expressions of interest in three acute care hospitals
Acknowledgements
For funding support from the School of Nursing and Findings
Midwifery, University of Western Sydney. The team nursing experiences of nurse managers are
described using three main categories: adapting to
To the nurse managers who volunteered to participate team nursing, gains with team nursing and concerns
in this study. with team nursing.
To Miss Jacqueline Britton and Ms Brenda Hayman for
Conclusions
their support with transcription and encoding in NVivo
Nurse managers considered gains for staff and
and Dr Joanne Cummings for editorial assistance.
patients were made with the implementation of a
teambased approach to nursing care. This teambased
approach to care was regarded by managers to
Key words enable nursing staff of varying experience and skill
to provide care more safely as direct supervision by
team nursing, nurse managers, acute care,
more experienced staff was possible. However the role
experiences, models of care, staffing
of team leader necessitated staff development and
support to enhance clinical leadership skills involved in
this new role.

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INTRODUCTION stay in nursing, they are more productive, errors are


reduced, quality is improved and patients are more
Clinical nurse managers are expected to oversee the
satisfied (pp.1).
delivery of patient care that is safe and meets quality
standards within the available human, financial Recently the implementation of team nursing
and material resources. Staffing, particularly the approaches to address changing skill mix has been
available skill mix, is often a challenge for nurse reported both internationally (Dobson et al 2007) and
managers faced with this accountability in an nationally (Walker et al 2007; OConnell et al 2006).
environment where it is difficult to recruit and retain In Australia nursing care delivery is moving away from
experienced nursing staff and to offer a supportive patient allocation towards team nursing models of
learning environment for inexperienced nurses. care (Walker et al 2007; NSW Health 2006).
Evidence indicates that various forms of team
Experiences with team nursing
nursing are being adopted in acute care settings to
Experiences of nurses delivering care in teams have
provide safe patient care using a more diverse skill
been explored from the perspective of nurses, team
mix (NSW Health 2007; Walker et al 2007; Walker
leaders and nurse managers. Nurses perceptions
2002). Teamwork both within nursing teams and in
of team nursing have identified benefits for patients
collaboration with multidisciplinary teams is said to be
as being continuity of care (Cioffi and Ferguson
crucial to producing better quality care and reducing
2009; OConnell et al 2006) and delivery of safer
risk to patients (Rathert and Fleming 2008). Despite
and better quality care (Cioffi and Ferguson 2009;
the increasing diversity of the skill mix within the
Jupp 1994). For nurses the benefits have been
workplace and the importance of teamwork being
identified as improved working relationships (Cioffi
advocated as an essential approach to practice,
and Ferguson 2009; OConnell et al 2006; Hyrkas and
little is known about nurse managers experiences
AppelqvistSchmidlechner 2003); increased ability to
with team nursing in acute care wards. This study
share and work together (Cioffi and Ferguson 2009;
explored with nurse managers their experience of
OConnell et al 2006; Jupp1994) and availability of a
a teambased approach to nursing care delivery in
shared network (Cioffi and Ferguson 2009). However,
acute care settings.
some issues identified with team nursing have been
inadequate preparation for team nursing (Cioffi and
LITERATURE REVIEW
Ferguson 2009; Jupp1994); increased responsibility
Team nursing for registered nurses particularly when in the role of
Team nursing developed in the 1950s in response to team leader (Cioffi and Ferguson 2009); unfair and
changes in nursing skill mix. This approach requires uneven workloads leading to overburdening of staff
strong leadership and excellent communication skills (OConnell et al 2006) and confusion around roles
to bring together small groups of nurses, led by a team and responsibilities in the team (OConnell et al 2006;
leader, to work collaboratively and cooperatively to Jupp 1994). Other challenges with communications
deliver a better standard of care than possible with and teamwork have been attributed to the varied
individual nurses working alone (Dobson and Tranter skill mix; the lack of familiarity with ward routine
2008; Shirley 2008; Tiedeman and Lookinland 2004; and assigned patients; and busy, pressured work
Sherman 1990). Recently Spitzer (2008, pp.6) drew conditions (Cioffi and Ferguson 2009; OConnell
attention to the importance of teams in maximising et al 2006). Team leaders reported that their job
staff and providing environments for professionals satisfaction improved particularly through enhanced
to apply their education and skills while working relationships and seeing staff develop (Jupp 1994).
with others who can provide caring services under These findings clearly indicate gains for both patients
the registered nurses direction. According to Kalisch and staff can be made with team nursing.
et al (2009), where teamwork is effective nurses

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From the perspective of nurse managers, findings Data collection procedures


show relationships for patients, relatives and staff Data were collected by the researchers using
improved, staff morale and motivation increased and interviews with nurse managers to explore their
communications improved (Jupp 1994). However experience with team nursing. The interviews were
managers who implemented team nursing identified scheduled in each hospital to facilitate access;
retrospectively that more information and educational they were audiotaped and lasted about one hour.
support was essential (Jupp1994). As little is currently A topic guide was available and used only to raise
known about nurse managers experiences with areas if participants did not include them in their
team nursing this study explored and described overall descriptions of their experiences. Participants
managers experiences of team nursing in acute completed consent and demographic forms prior to
care settings. the interviews.

Data analysis procedures


METHOD
The audiotapes were transcribed verbatim,
Design checked and textual data coded and categorised
A qualitative study to identify and describe nurse using Liamputtong and Ezzys (2005) inductive
managers experiences of team nursing in acute care interpretative approach to qualitative analysis.
wards was undertaken. A descriptive approach within Personal information about participants was
the framework of naturalistic inquiry was selected summarised using descriptive statistics.
as little is known about managers experiences with
team nursing in acute care wards (Erlandson et al. FINDINGS
1993; Lincoln and Guba 1985).
Nurse managers experiences of team nursing can be
Setting described using three main categories: adapting to
The study setting was three acute care hospitals, team nursing, gains with team nursing and concerns
two metropolitan tertiary referral and one general with team nursing.
teaching hospital in an area health service in NSW,
Adapting to team nursing
Australia. Managers described the change to team nursing as
Sample being influenced by skill mix, inadequate supervision
From calls for expressions of interest sent to three of less experienced staff by senior staff, the altered
hospitals, only five nurse managers volunteered to role of the enrolled nurse and attrition of experienced
staff. However skill mix was identified as the main
participate in the study. The inclusion criteria were:
factor for changing to team nursing as nursing staff
a nurse manager in an acute care adult ward with a
were less experienced and less skilled, requiring
teambased approach to nursing care delivery. The
an increased level of direct supervision. A typical
size of the purposive sample is small but appropriate
comment was:
for a qualitative study as Kuzel (1999) suggests
a range between five to twenty persons. Ethics first year graduates, trainee enrolled nurses,
enrolled nurses (EN), undergraduates need to team
protocols were approved by the area health service
nurse with that group of skill mix they have to be
and university Human Research Ethics Committees.
led and guided by a registered nurse
The participants were registered nurses with a
mean of four and half years experience as a nurse From the managers descriptions team nursing was
manager in an acute care ward and a median of ten commenced with minimal preparation on a trial and
years experience with team nursing. There were error basis, for example:
four female and one male participants; two held a took it to a ward meeting for discussion we
masters degree, one a bachelor degree and two held started with three weeks it was a bit of trial and
postgraduate certificates. error

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On reflection managers identified areas they could its happening more these days where your juniors
have planned differently including the need for staff are your seniors got to skill them up pretty quick
to be involved and have ownership of the change, and get them confident enough when you do have a
to develop a shared understanding of team nursing few of your seniors on, then you put your most junior
and the critical nature of communication in teams, person as team leader and then the other people
and the need to set a timeframe for the change, for are there as a resource
example:
team leader accountable for patient care in
important to talk about what you think team such a way the supervision is more effective and the
nursing is and how you think it will run and really patient care is more guaranteed there are times
keep it open for feedback at the start I would say when you have to be firm .there are times when
definitely some education on communication. I think you really need to discuss things and empower them
that is a major issue. and get their feedback. important to keep them in
the loop
Youve got to involve them, give them time to adjust,
but then you have to put a timeframe on that... positive reinforcement, praise where praise
is due and dealing with the nitty gritty stuff be
Managers indicated that senior staff were not as
approachable have it clearly documented this
keen as the junior or less skilled staff about the
is what is expected followup on the disciplinary
team nursing approach to care. Being responsible
process if you need to
for a greater number of patients and for supervising
team members underlay this lack of enthusiasm as The consequence of staff not being adequately
shown in extracts below: supported was noted by managers. As one manager
said:
The senior staff took a little longer to come around
to it they battled with the extra responsibility if we dont support them, then we lose them,
and then we are working under even under more
Instead of thinking about only four patients, has
pressure, because you have got less skilled staff
got to think for the other 10 or 15 or 18.
on the ward
The managers talked about the need for nurses
Gains with team nursing
to be well prepared for different roles within the
Managers outlined the gains made with team nursing
team specifically the need for the team leader
through a comparison with the patient allocation
to accept accountability for team performance.
model that had been the predominant model
Managers described using reassurance and
of care delivery prior to the introduction of team
positive reinforcement with teams; including the
nursing. This comparison identified team nursing as
staff in decision making, building independence
enabling nurses to have a more complete picture
and providing the means for nurses to empower
of all the patients, facilitating better coverage over
themselves to make practice decisions within the
breaks, encouraging more independence in staff
teams. Strategies they used were mentoring, learning
and positioning seniors in the team to accept greater
packages, upskilling of staff, setting and managing
responsibility for supervising junior and less skilled
expectations and dealing with resistance to change.
staff. For the patients it was considered to result in
Typical comments were:
more contact with nurses, better quality care and a
developed a team leader package and a safer environment. Some typical comments were:
mentorship program. So we focus on the work. the
so if one is off on a break another person there
people as a leader, but they need to be trained, so
who knows what is going on with that group of patients
we give them feedback as well and say this is your
continue with care.
weakness.

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this way everyone gets a senior and a junior (staff Typical comments were:
looking after them). The patients know there is
If you dont communicate ultimately its the patient
always a senior around looking after them
whos comprised after the verbal handover then
in a team a lot better quality of care a safer the teams go around visualise the patients
environment if you have RNs, ENs, first year grads Becoming standard practice talk about it at ward
working together meetings and just on one on one performance
appraisals
Further gains managers highlighted were the
networks engendered by the team leader and nurses a handover sheet checks happen every
supporting each other and the increased learning shift
opportunities that arose with more experienced
Another concern was that related to communications
nurses working with less experienced nurses. Typical
between the nursing teams and medical staff,
comments were:
although there was acknowledgement that this had
gain so much more as part of a team that support improved. For example:
network its everything because you are not on your
probably our worst communicators at times are
own, you are not getting overwhelmed
the medical staff they dont write it compared
work with a senior person maybe once or twice to just a couple of years ago, its improved
a week feel more comfortable around them
A further concern for nurse managers was the
learn with that rapport there are more learning
perceived relationship of the nursing team to the
opportunities
multidisciplinary team. Though managers described
Managers identified that team nursing had impacted a greater awareness by nursing teams of the whole
on nurses relationship with other health professionals team involvement in patient care they specifically
engendering increased liaison, increased opportunity identified a need for junior nursing staff to attend
for education, greater potential to coordinate care and participate in multidisciplinary team meetings.
and improved patient outcome orientation, for
morbidity and mortality meetinglook at any
example:
incidents or how we can do things better and junior
We have social worker, occupational therapist, staff should be attending those as well
physiotherapist, dietician meeting once a week
they are more ready to communicate with us. In the DISCUSSION
past, they tended to work alone now they see us as Main findings show nurse managers experiences
a team always come looking for us and see how of team nursing focused on the adaptation to team
we improve the patients meet together to try to nursing with its associated gains and concerns.
improve the patient flow. Managers identified that similar factors had
Concerns with team nursing precipitated the change to team nursing within
A key concern for effective team functioning identified their ward areas and it was acknowledged the
by managers was the teams ability to communicate implementation process needed to be better planned
effectively. Managers were acutely aware poor to include collaboration with staff, clear protocols
communication within the team placed both team and roles for teams. Main gains achieved with team
members and patients at risk. They described nursing for patients were more contact with nurses,
active management of this concern addressing better quality care in a safer environment and for less
communication at ward meetings, performance skilled and less experienced nurses, better support
appraisals and with the use of shift communication and direct supervision. This supports previous
sheets, handover sheets, and walkaround reports. findings that teambased models can improve patient

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safety, quality of care and the work environment effective teamwork and recommended its inclusion
(Cioffi and Ferguson 2009; Jupp 1994). However in the preparation for team nursing with ongoing
concerns were identified including the need support during and after implementation.
to support and develop team leaders for their
LIMITATIONS
increased level of responsibility and to ensure
effective communications within both the nursing The main limitation of this study is the small number
and multidisciplinary teams. of nurse managers who volunteered to participate
despite repeated attempts to recruit managers from
Findings from this study support earlier findings
three sites. Difficulty with recruiting may reflect their
(Dobson et al 2007; Walker et al 2007; NSW Health
heavy managerial workloads with many competing
2006; OConnell et al 2006) that show team nursing
demands and the underdeveloped research culture
can accommodate a workforce of varied skill mix with
of the clinical settings. Findings therefore only reflect
enrolled nurses, first year graduates and student
the experiences of a few managers. This small
nurses as they can be supported and supervised on
study can provide a guide to the development of
shifts. Managers identified that inexperienced staff
further studies that are needed to more extensively
found the supportive environment of team nursing
describe team nursing experiences from a managerial
resulted in them feeling more comfortable, enabling
perspective.
supervised learning and reducing feelings of being
overwhelmed and isolated. The more experienced
CONCLUSIONS
nurses who had to assume the team leader role and
take responsibility for team performance found team The findings of this study highlights managers
nursing more stressful and required support and agreement that team nursing is a key strategy to
development for the leadership role. As identified in be employed when the nursing skill mix consists
previous studies (Cioffi and Ferguson 2009; OConnell predominantly of less experienced registered and
et al 2006; Jupp 1994) the nurse managers in this enrolled nurses who require constant supervision
study considered benefits for patients were achieved and support. The positive effect of team nursing on
with a team nursing approach to care including working environments particularly for junior staff
more direct contact with nurses and care that can contribute to improved quality and safety of
was delivered more safely with quality monitoring patient care. However, senior staff require support
occurring. Overall managers were positive about to enhance their clinical leadership skills to enable
team nursing recognising its goodness of fit to the them to manage the additional responsibilities of
available staff mix. leading teams in acute care settings.

In the early days of implementing team nursing The findings also emphasise the importance of good
managers described the change as predominantly planning, consultation with staff, clear definition
one of trial and error, a finding also identified by of the team nursing model and the expected roles
Cioffi and Ferguson (2009) and Jupp (1994). The and responsibilities of all team members prior to
change process described suggests that a more the implementation of the team nursing model of
structured and planned approach to the transition care. There is evidence to suggest that relationships
to team nursing was required with staff involvement between the nursing and the multidisciplinary
in planning, more emphasis on the development team were improved with team nursing, however
of a common understanding of team nursing and
opportunities remain for this relationship to
of the roles and responsibilities of team members,
be strengthened with further attention paid to
specifically the role of team leader with its greater
communication between members of the various
responsibilities. Further to this, managers were aware
teams.
that communication was a critical component of

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